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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006150
Report Date: 01/08/2025
Date Signed: 01/08/2025 10:02:54 AM

Document Has Been Signed on 01/08/2025 10:02 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CALIFORNIA CARE MENTAL HEALTHFACILITY NUMBER:
306006150
ADMINISTRATOR/
DIRECTOR:		BOUQUET, JASONFACILITY TYPE:
772
ADDRESS:25542 DANA MESA DRTELEPHONE:
(949) 291-3333
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 4DATE:
01/08/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Nathaniel ArmentaTIME VISIT/
INSPECTION COMPLETED:
10:17 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit to the facility for the purpose of delivering an amended version of the deficiency pages (LIC809-D) cited during complaint investigation and generated on June 13, 2024 and September 9, 2024. LIC809-D was amended to reflect subsections cited under "Section Number".

LPA discussed the amendment with Behavioral Health Technician Nathaniel Armenta. An exit interview was conducted and a copy of this report was provided at the end of the visit.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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